Natural History, Complications and Prognosis

Complications

Prognosis

Treatment with physical therapy and NSAIDs will usually restore motion and function of the shoulder within a year. Even untreated, the shoulder can get better by itself in 24 months.

After surgery restores motion, you must continue physical therapy for several weeks or months to prevent the frozen shoulder from returning. Treatment may fail if you cannot keep up with physical therapy.

Diagnosis

History and Symptoms

Movement of the shoulder is severely restricted. The condition is sometimes caused by injury that leads to lack of use due to pain but also often arises spontaneously with no obvious preceding trigger factor. These seemingly spontaneous cases are usually referred to as Idiopathic Frozen Shoulder. Rheumatic disease progression and recent shoulder surgery can also cause a pattern of pain and limititation similar to frozen shoulder. Intermittent periods of use may cause inflammation.

Abnormal bands of tissue (adhesions) grow between the joint surfaces, restricting motion. There is also a lack of synovial fluid, which normally helps the shoulder joint move by lubricating the gap between the humerus (upper arm bone) and the socket in the scapula (shoulder blade). It is this restricted space between the capsule and ball of the humerus that distinguishes adhesive capsulitis from a less complicated, painful, stiff shoulder. People with diabetes, stroke, lung disease, rheumatoid arthritis, and heart disease, or who have been in an accident, are at a higher risk for frozen shoulder. Adhesive capsulitis has been indicated as a possible adverse effect of some forms of highly active antiretroviral therapy (HAART). The condition rarely appears in people under 40 years old and (at least in its idiopathic form) is much more common in women than in men (70% of patients are women aged 40-60). Frozen shoulder in diabetic patients is generally thought to be a more troublesome condition than in the non-diabetic population. [2] If a diabetic patient develops frozen shoulder then the time to full recovery is often prolonged from the usual 12 month period.

Physical Examination

With a frozen shoulder, one sign is that the joint becomes so tight and stiff that it is nearly impossible to carry out simple movements, such as raising the arm.
People complain that the stiffness and pain worsen at night. Pain due to frozen shoulder is usually dull or aching. It can be worsened with attempted motion. A doctor, or therapist (occupational, massage or physical), may suspect the patient has a frozen shoulder if a physical examination reveals limited shoulder movement. Frozen shoulder can also be diagnosed if limits to the active range of motion (range of motion from active use of muscles) are the same or almost the same as the limits to the passive range of motion (range of motion from a person manipulating the arm and shoulder).

Physicians have described the normal course of a frozen shoulder as having three stages:[3]

Stage one: In the "freezing" or painful stage, which may last from six weeks to nine months, the patient has a slow onset of pain. As the pain worsens, the shoulder loses motion.

Stage two: The "frozen" or adhesive stage is marked by a slow improvement in pain, but the stiffness remains. This stage generally lasts four months to nine months.

Stage three: The "thawing" or recovery, during which shoulder motion slowly returns toward normal. This generally lasts five months to 26 months.

MRI

An arthrogram or an MRI scan may confirm the diagnosis - although in practice this is rarely required. Most orthopedic specialists make the diagnosis of frozen shoulder by recognizing the typical pattern of signs and symptoms.

Shown below are MRI images from a patient with adhesive capsulitis.

Treatment

Medical Therapy

Management of this disorder focuses on restoring joint movement and reducing shoulder pain. Usually, it begins with nonsteroidal anti-inflammatory drugs (NSAIDs) and the application of heat, followed by gentle stretching exercises. These stretching exercises, which may be performed in the home with the help of a physical, massage or occupational therapist, are the treatment of choice. In some cases, transcutaneous electrical nerve stimulation (TENS) with a small battery-operated unit may be used to reduce pain by blocking nerve impulses. The next step often involves one or a series of steroid injections (up to six).

If these measures are unsuccessful, the doctor may recommend manipulation of the shoulder under general anesthesia to break up the adhesions. Surgery to cut the adhesions is only necessary in some cases.

Primary Prevention

To prevent the problem, a common recommendation is to keep the shoulderjoint fully moving to prevent a frozen shoulder. Often a shoulder will hurt when it begins to freeze. Because pain discourages movement, further development of adhesions that restrict movement will occur unless the joint continues to move full range in all directions (adduction, abduction, flexion, rotation, and extension). Therapy will help one continue movement to discourage freezing and warm it. A medical doctor referral is needed before occupational or physical therapy can begin under law in most US states. Medical referral is not required for physical or occupational therapy in most Canadian provinces.